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newSchoolWorks.com › VoTechWorks › Health & Personal Services › Respiratory Therapy › Capstone Project: Integrated Respiratory Therapy Case Design and Defense › Lesson 1
HLT-RESP80-07 · Lesson 1 · 96 clock hours · theory

Case Selection, Patient Assessment Synthesis, and Project Scoping

Objective. Students select an approved complex patient case scenario and produce a comprehensive written patient assessment that synthesizes cardiopulmonary history, physical examination findings, laboratory values, and diagnostic results into a prioritized problem list.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.

VoTechWorks program approval and accreditation are still in progress. Credentials are issued only by the certifying bodies named in each program, after their own exams.

Why Case Selection Matters

The capstone project is your opportunity to demonstrate that you can function as an entry-level respiratory therapist across the full scope of practice. Choosing the right patient scenario is therefore not a casual decision. A well-chosen case must span multiple program domains—airway management, mechanical ventilation, blood gas analysis, pharmacology, patient education, and interdisciplinary communication—so that your defense reflects genuine clinical integration rather than a narrow skill set.

Three approved complex scenarios are available: an ARDS patient receiving mechanical ventilation, a patient in severe COPD exacerbation with hypercapnic respiratory failure, and a post-operative thoracic surgery patient developing atelectasis. Each case has been designed to contain sufficient physiological complexity. Your case-selection worksheet asks you to map each scenario against the program's core domains and choose the one that best challenges your individual learning gaps. Documenting that reasoning is the first professional act of the project.

Synthesizing the Patient Assessment

A professional patient assessment is not a list of facts copied from a chart. It is a reasoned synthesis: you gather data from multiple sources, reconcile conflicts, and draw clinically supported conclusions. For this project you will produce a written assessment that includes the following sections.

Chief Complaint and History of Present Illness. State the patient's primary reason for seeking care in their own words, then describe the timeline and progression of symptoms. Dyspnea that worsens over three days tells a different story than sudden-onset respiratory distress.

Respiratory, Medical, and Surgical History. Chronic conditions such as COPD, asthma, or obstructive sleep apnea alter baseline values and change what counts as abnormal for a given patient. Prior thoracic surgery affects chest-wall mechanics. Document these carefully because they directly influence your problem list.

Physical Examination Findings. Record breath sounds bilaterally (clear, diminished, crackles, wheezes, rhonchi), work of breathing (use of accessory muscles, nasal flaring, paradoxical breathing, retractions), respiratory rate, heart rate, blood pressure, oxygen saturation, and temperature. These objective findings must match and explain the subjective complaints.

ABG Interpretation. Apply a systematic method every time: (1) assess pH for acidosis or alkalosis, (2) examine PaCO₂ for respiratory contribution, (3) examine HCO₃⁻ for metabolic contribution, (4) determine whether compensation is present, and (5) assess oxygenation via PaO₂ and the A-a gradient when relevant. State the complete interpretation in clinical language, for example: "Partially compensated respiratory acidosis with hypoxemia."

Pulmonary Function Data. Identify obstructive, restrictive, or mixed ventilatory defects using standard reference patterns. Note the severity classification when spirometry values are provided. Remember that PFT interpretation requires comparison to predicted values based on age, sex, height, and race/ethnicity.

Imaging Findings. CXR descriptions in your case packet will describe findings such as hyperinflation, infiltrates, pleural effusion, or atelectasis. Translate these findings into clinical meaning—what do bilateral lower-lobe infiltrates suggest in the context of a post-operative patient who is not deep-breathing?

Prioritized Problem List. This is the intellectual core of the assessment. List every patient problem you have identified, then rank them by urgency and clinical significance. Life-threatening airway or oxygenation problems always appear first. Each item must be supported by data from the chart—never add a problem you cannot defend with evidence.

Scope of Practice and Safety

Every statement in your written assessment must remain within the respiratory therapist's scope of practice as defined by your state's practice act and by NBRC competency frameworks. You may identify a problem and recommend a diagnostic or therapeutic intervention, but you do not independently order medications, interpret radiographs as a radiologist would, or establish medical diagnoses. Use language such as "assessment findings are consistent with" rather than "the patient has" when describing pathological conditions. Scope-of-practice errors on your rubric result in automatic point deductions and signal a patient-safety concern.

Data accuracy is equally non-negotiable. Transcribing an ABG value incorrectly or misreading a PFT table can produce a completely wrong problem list, leading to treatments that harm rather than help a real patient. Check every number against the source document before finalizing your write-up.

The Scoping Session

After submitting a draft, you will defend your problem list in a small-group session. Peers and the instructor will challenge your reasoning: Why is this item ranked above that one? What would a normal PaCO₂ be for a patient with chronic CO₂ retention? What physical exam finding supports your claim of bronchospasm? This process mirrors real clinical rounds. You are expected to revise your document based on legitimate challenges. Updating your assessment when presented with good evidence is a sign of clinical competence, not weakness.

Documentation Standards

Use the provided clinical documentation template. Write in professional clinical language—objective, precise, free of slang. Avoid vague terms like "lungs sound bad." State "bilateral expiratory wheezes heard at the lung bases" instead. Abbreviations must be on the approved abbreviation list. Your assessment will be evaluated on accuracy of interpretation, completeness, professional format, and absence of scope-of-practice errors using the 20-point rubric; you must earn at least 16 points (80%) to pass.

Key terms9

Patient assessment synthesisThe process of gathering data from multiple clinical sources—history, physical exam, laboratory values, imaging—and integrating them into a coherent, prioritized clinical picture rather than treating each finding in isolation.
Prioritized problem listAn ordered list of the patient's active clinical problems ranked by urgency and severity, with each item supported by objective data; life-threatening airway and oxygenation problems appear first.
ABG interpretationSystematic analysis of arterial blood gas values to identify acid-base disturbances (acidosis or alkalosis), determine their primary cause (respiratory or metabolic), assess compensation, and evaluate oxygenation status.
Ventilatory defectA pattern seen on pulmonary function testing; an obstructive defect is characterized by reduced airflow rates, a restrictive defect by reduced lung volumes, and a mixed defect by features of both.
Scope of practiceThe range of services, procedures, and clinical decisions that a respiratory therapist is legally and professionally authorized to perform, as defined by the state practice act and NBRC competency standards.
Hypercapnic respiratory failureRespiratory failure characterized by an elevated PaCO₂ (generally above 45 mmHg) accompanied by acidosis, resulting from inadequate alveolar ventilation; also called Type II or ventilatory failure.
A-a gradientThe alveolar-arterial oxygen gradient, a calculated value that reflects the efficiency of gas exchange across the alveolar membrane; an elevated gradient suggests a V/Q mismatch, shunt, or diffusion defect.
Clinical documentation standardsAccepted conventions for recording patient information in a healthcare setting, including objective and precise language, approved abbreviations, accurate transcription of data, and avoidance of unsupported conclusions.
Compensation (acid-base)The physiological response that partially corrects a primary acid-base disturbance; the respiratory system compensates for metabolic disorders by adjusting PaCO₂, while the kidneys compensate for respiratory disorders by adjusting HCO₃⁻.
In class: Review a library of three approved complex case scenarios (e.g., ARDS patient on mechanical ventilation, severe COPD exacerbation with hypercapnic respiratory failure, post-operative thoracic surgery patient with atelectasis) and complete a structured case-selection worksheet justifying their choice based on breadth of content coverage across program domains. · Draft a full written patient assessment document including chief complaint, respiratory history, relevant medical and surgical history, physical examination findings (breath sounds, work of breathing, vital signs), ABG interpretation, pulmonary function data, imaging findings, and a prioritized problem list formatted to professional clinical standards. · Participate in a facilitated small-group scoping session where peers and the instructor challenge the student's problem list and initial assumptions, requiring the student to defend each item with physiological rationale and revise the document based on structured feedback.
Materials: Approved case scenario packets with simulated chart data (ABG reports, PFT reports, CXR descriptions, lab panels), AARC Clinical Practice Guidelines (current edition), Scanlan's 'Egan's Fundamentals of Respiratory Care' (current edition), professional clinical documentation templates, rubric for patient assessment write-up
Check: Completed patient assessment document scored against a 20-point rubric covering accuracy of data interpretation, completeness of problem list, professional documentation format, and absence of scope-of-practice errors; minimum passing score is 16/20 (80%).

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Patient Assessment and Evaluation
1. A student's prioritized problem list places "patient anxiety" above "SpO₂ 82% on room air." Which of the following best describes this error?
Arterial Blood Gas Analysis
2. An arterial blood gas shows pH 7.28, PaCO₂ 62 mmHg, HCO₃⁻ 28 mEq/L, PaO₂ 54 mmHg on 2 L/min nasal cannula. Which interpretation is correct?
Professional and Ethical Practice
3. When writing a clinical patient assessment, a respiratory therapy student states: "The patient has pneumonia." Which revision best reflects appropriate scope of practice?
Pulmonary Diagnostics
4. A spirometry report shows FEV₁/FVC ratio below the lower limit of normal with a reduced FEV₁ and a near-normal FVC. This pattern is most consistent with which type of ventilatory defect?
Therapeutic Procedures and Patient Safety
5. During the scoping session, a peer challenges a student's inclusion of "risk for ventilator-associated pneumonia" on the problem list for an ARDS patient on mechanical ventilation. What is the best way for the student to defend this item?
Patient Assessment and Evaluation
6. A post-operative thoracic surgery patient has diminished breath sounds at the left base, decreased SpO₂, and a CXR description noting increased opacity at the left lower lobe. Which problem should the student list first?
Patient Assessment and Evaluation
7. Which component of the patient assessment most directly demonstrates the student's ability to integrate data from multiple sources rather than simply reporting individual values?
Professional and Ethical Practice
8. A student's written assessment describes breath sounds as "bad bilaterally." An instructor marks this as a documentation error. Which entry would be most appropriate?
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